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Plasmapheresis Technique

  • Author: Elliot Stieglitz, MD; Chief Editor: Emmanuel C Besa, MD  more...
 
Updated: Dec 21, 2015
 

Plasmapheresis

Steps in therapeutic plasma exchange

The following is an example of the steps involved in performing therapeutic plasma exchange using centrifugation-based equipment such as the Spectra Auto PBSC:

  • Any heparin that may be present in each of the two lumens of a central venous catheter is removed
  • A waste of 3 mL is then discarded
  • Laboratory studies, including complete blood count (CBC), calcium, and fibrinogen, are ordered and specimens sent from the draw lumen
  • A flush with 10 mL of normal saline is placed in the draw lumen
  • The draw and return lumens are then connected to the tubing, which is previously primed with normal saline; however, if a patient weighs less than 20 kg, then the draw and return tubing is primed with packed red blood cells (RBCs) instead of normal saline
  • Height and weight are then entered into the system to allow estimation of total blood volume (TBV)
  • Plasma volume is then calculated as follows: TBV × (1 – hematocrit)
  • A replacement product is chosen
  • The total volume of the desired replacement product is entered—usually either 1 plasma volume (40 mL/kg) or 1.5 plasma volume (60 mL/kg)
  • A centrifuge speed is determined by the software on the basis of the data entered
  • The device then draws whole blood through the draw lumen to the centrifuge
  • Plasma is separated by the centrifuge and collected for discard
  • RBCs are also separated by the centrifuge, then returned to the patient along with the previously selected colloid of either albumin or fresh frozen plasma (FFP)
  • After the desired amount of plasma is removed, the machine is disconnected from the patient, and heparin is instilled into each catheter lumen to prevent clotting until the lumen is accessed again
  • A post–plasma exchange fibrinogen level is checked if albumin was used as the replacement product (albumin does not contain fibrinogen, as opposed to FFP) to assess whether the patient has become severely hypofibrinogenemic

Replacement products

Options for replacement fluid during plasma exchange include albumin, electrolyte solutions, hydroxyethyl starch, FFP, and purified protein products such as individual clotting factors or antithrombin III.[13] Deciding which replacement product to use is based on the underlying condition and the risks and benefits associated with each replacement product. In general, albumin is the most common replacement product because of its low side-effect profile and broad availability.[13]

Symptomatic adjustments

If signs of hypocalcemia are present, replacement calcium can be administered either intravenously or orally. Additionally, the whole blood–to–citrate ratio can be titrated to minimize hypocalcemic symptoms, which are usually related to the amount of citrate being used as an anticoagulant.[14]

If signs of hypomagnesemia are present, replacement magnesium can be administered intravenously.

If signs of general discomfort are present, the return rate can be adjusted downward.

If signs of hypotension are present, normal saline boluses can be administered.

If signs of a transfusion reaction are present, the product infusion is discontinued, and diphenhydramine and hydrocortisone are given. In cases of anaphylaxis or respiratory distress, epinephrine can be administered as well.

Special considerations in pediatric patients

Magnesium is not always given prophylactically, though the decision is physician-dependent.[15]

If a patient weighs less than 20 kg, the draw and return tubing are primed with packed RBCs instead of normal saline.

Return rates of blood product are on the order of 1.5 mL/kg/min, as opposed to the standard 70 mL/min flat rate used in adults.[16]

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Complications

Patients can experience symptoms of hypocalcemia and or hypomagnesemia during and after the procedure and can be treated with replacement calcium and magnesium, respectively.[17]

Patients frequently become hypothermic during the procedure, in which case they should be warmed appropriately.

Patients can experience transfusion-related reactions, in particular with FFP, and should be treated with diphenhydramine, hydrocortisone, and/or epinephrine depending on the severity of the reaction. These reactions can occur during and after the transfusion.

Patients can experience hypotension as a result of rapid fluid shifts, and proper precautions should be taken to minimize complications such as unintended falls.

Patients can become thrombocytopenic and hypofibrinogenemic after plasmapheresis (especially if albumin is being used as a replacement product) and should be monitored for signs of bleeding.

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Contributor Information and Disclosures
Author

Elliot Stieglitz, MD Pediatric Oncologist, University of California, San Francisco, School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

James Huang, MD Clinical Professor of Pediatrics, Director of Pediatric Hematology, University of California, San Francisco, School of Medicine

James Huang, MD is a member of the following medical societies: American Society of Hematology, American Society of Pediatric Hematology/Oncology, Hemophilia and Thrombosis Research Society

Disclosure: Received grant/research funds from Baxter Healthcare Corporation for research; Received grant/research funds from BPL for research.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors wish to thank Beth DuVardo, RN, and Lillian Larue, RN, of the Apheresis Unit at University of California, San Francisco, School of Medicine for their assistance with this article.

References
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  2. Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, et al. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher. 2010. 25(3):83-177. [Medline].

  3. Siami GA, Siami FS. Membrane plasmapheresis in the United States: a review over the last 20 years. Ther Apher. 2001 Aug. 5(4):315-20. [Medline].

  4. Gerhardt RE, Ntoso KA, Koethe JD, Lodge S, Wolf CJ. Acute plasma separation with hemodialysis equipment. J Am Soc Nephrol. 1992 Mar. 2(9):1455-8. [Medline].

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  10. Chang CT, Tsai TY, Liao HY, Chang CM, Jheng JS, Huang WH, et al. Double Filtration Plasma Apheresis Shortens Hospital Admission Duration of Patients With Severe Hypertriglyceridemia-Associated Acute Pancreatitis. Pancreas. 2015 Oct 21. [Medline].

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  18. Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. 2000 Nov 7. 133(9):676-86. [Medline].

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